MAUDE Adverse Event Report: STERIS MEXICO, S. DE R.L. DE C.V. AMSCO 400 STERILIZER

Model Number	AMSCO 400 STEAM STERILIZER
Medical Device Problem Codes	Use of Device Problem (1670); Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/06/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Investigation of the reported event is currently in process.A follow-up report will be submitted when additional information becomes available.
Event or Problem Description
The user facility reported that their amsco 400 sterilizer was producing wet instrument packs following completed cycles.This caused patient procedures to be postponed.No report of injury.
Additional Manufacturer Narrative
A steris service technician arrived onsite to inspect the unit and found that the steam trap had failed as it was dirty and clogged.As the steam trap was clogged, steam could not travel down the drain resulting in excess steam within the unit and therefore the reported wet instrument packs.The technician rebuilt the steam trap and proactively cleaned the water level probes.The technician tested the unit, confirmed it to be operating according to specification, and returned it to service.The technician collected water samples to test the facility's incoming water and the results identified that six of the critical chemical attributes of water quality were above the maximum requirements for the carbon-steel steam generator as stated in the amsco 400 sterilizer operator manual.(table 5-1.Required feed water quality for carbon-steel steam generators).The user facility is responsible for ensuring that their incoming water supply remains within the carbon-steel steam generator's operating requirements.The amsco 400 operator manual states (3-1), "water quality - supplied must be within specifications.Improper water quality adversely affects equipment operation." the technician notified the customer of the water quality test results and that their water quality is not meeting the required operating conditions.The user facility has committed to making the necessary improvements to the facility's incoming water quality.No additional issues have been reported.

• Brand Name: AMSCO 400 STERILIZER
• Common Device Name: STERILIZER
• Manufacturer (Section D): STERIS MEXICO, S. DE R.L. DE C.V.; avenida avante 790; parque industrial guadalupe; guadalupe, 67190 ; MX 67190
• Manufacturer (Section G): STERIS MEXICO, S. DE R.L. DE C.V.; avenida avante 790; parque industrial guadalupe; guadalupe, 67190 ; MX 67190
• Manufacturer Contact: daniel davy ; 5960 heisley road; mentor, OH 44060 ; 4403927453
• MDR Report Key: 16506348
• Report Number: 3005899764-2023-00012
• Device Sequence Number: 16982280
• Product Code: FLE
• UDI-Device Identifier: 00724995209421
• UDI-Public: 00724995209421
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 03/08/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: AMSCO 400 STEAM STERILIZER
• Device Catalogue Number: SR0201110111
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/06/2023
• Supplement Date Received by Manufacturer: 02/06/2023
• Initial Report FDA Received Date: 03/08/2023
• Supplement Report FDA Received Date: 06/06/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 09/27/2022
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown